
Book JH3 



Special 
Autopsy Methods 



By WILLIAM G. MACCALLUM 



Issued from the Surgeon General's Office 
for the Use of Army Officers. 



APRIL 13, 1918 



Special 
Autopsy Methods 



By WILLIAM G. MACCALLUM 



Issued from the Surgeon General's Office 
for the Use of Army Officers. 



APRIL 13, 1918 



■■'■ 



^v,* 

V 



n. of B. 

NOV 19 1918 



For the standardization of methods in the perform- 
ance of autopsies in Base Hospitals the follow- 
ing suggestions are made : 

Removal of the Brain: 

Precautions must be taken to avoid the disfigurement of 
the corpse. Since removal of the calvarium is commonly per- 
formed for the investigation of cases in which meningitis is 
suspected it is important to make cultures from the meninges. 
If satisfactory cultures have been obtained from fluid removed 
by spinal prmcture, the head and neck may be embalmed before 
any scalp incision is made, since after removal of the brain 
satisfactory embalming of the face is difficult, if not impos- 
sible. If. however, it is important that cultures should be 
made from the cerebral meninges the scalp incision may be 
made, the calvarium removed and a flap of dura mater raised 
so that cultures can be obtained, after which the scalp should 
be replaced and the embalming performed. Some leakage 
occurs, but not enough to make the proper embalming of the 
face impossible. When this is completed the brain is removed 
for study. 

Certain elementary features of this whole procedure may 
be mentioned : 

1. The incision through the scalp begins behind one ear and 
passes upward over the top of the head and down to a similar 
point behind the other ear. If after beginning, the point of 
the knife is pushed under the scalp and the incision made with 
the edge turned outward the hair will not be cut, and will 
serve to cover the suture. The disastrous effect of making an 
incision round the head, across the forehead need not be 
mentioned. 

2. When, the scalp is loosened and pulled forward over the 
face and back over the occiput the skull is sawed through all 
around and the calvarium pulled off. The appearance of the 
forehead is better preserved if the saw incision passes across 
above the hair line and slants downward to meet the horizontal 



saw cut from the occipital region at an obtuse angle. It is 
much more difficult to remove the brain through such an open- 
ing. The remnants of the temporal muscle should be per- 
served, because by sewing through them on each side the cal- 
varium can be replaced accurately and held in place. Some 
substance which will absorb any excess of fluid and restore to 
some extent the weight of the head should be put into the 
cranial cavity. 

3. The scalp is most carefully sutured after replacing the 
calvarium, and the hair made to cover the suture as much as 
possible. The embalmed scalp must be moulded carefully over 
the skull. 

Removal of the Organs of the Neck: 

Again since embalming of the face is impossible after the 
blood vessels of the neck are cut, the embalming must be 
performed first.* This is readily done by the undertaker 
when the chest is open, but in his absence may be done very 
easily by anyone else. The undertaker's embalming fluids 
should be used if available; if not, an 8-10 per cent solution 
of formalin in water, to which a few drops of esosin solution 
are added to give it the faintest possible tinge of pink, is 
injected through the aorta with an alpha enema syringe. Of 
course the open end of the aorta as well as any leaking arteries 
( internal mammaries) must be closed with clamps. It is most 
convenient to tie the nozzle of the syringe into the descending 
aorta below the arch. As the fluid is pumped into the arteries 
and begins to drive blood before it out of the veins, the face 
and ears must be massaged and moulded with a gauze sponge 
into a natural pose, with eyes and lips closed. When the 
tissues become blanched and firm the process is complete. 

The actual removal of the organs of the neck may then be 
undertaken and is bound up with the making of the primary 
incision. 



*If shaving is necessary, it must be done before the face is embalmed. 



The Primary Incision: 

Ordinarily the incision runs from the supra-sternal notch 
to the pubes in a single straight line, but after such an incision 
it requires considerable dexterity to remove the organs of the 
neck without mangling the pharynx or nicking the skin. 

This task is rendered easy and the final appearance of the 
body more presentable if a different incision is made. This 
can be rendered plain by a drawing. (Fig. 1.) The median 
incision extends from about the middle of the sternum to the 
pubes. Across it at its upper point runs a transverse incision 
which curves up on each side to the anterior fold of the axilla 
and even down a short way on the upper arm. By dissection 
the whole skin of the upper part of the thorax and the neck 
can be thrown up like an apron over the face, exposing the 
whole lower edge of the lower jaw. Then the organs of the 
neck and the pharynx can be most easily dissected out. 

When the flap is replaced the space left by the removal of 
the larynx and trachea must be filled with some substance and 
the neck moulded into a natural form. When this is done no 
evidence of an incision is visible in the clothed corpse. 

The Lungs and Pleural Cavities: 

Since diseases of the respiratory organs loom so large in 
the present war certain suggestions may be made as to their 
study. 

A separate and detailed note should be made of the condi- 
tion of each pleural cavity, starting with the left, and cultures 
should be made from the pleural exudate. 

All possible care should be exerted not to tear the lung in 
removal. As a routine procedure the left lung should be 
removed and described first. W hen the lung has been removed 
to the small wooden table which stands on the autopsy table, 
cultures are made from the most obviously affected area. The 
pleural surface is seared with an old table knife heated in a 
Bunsen flame. A pair of toothed forceps and a pair of sharp- 
pointed scissors have been wrapped separately in paper and 

5 



sterilized in the hot-air oven. These are unwrapped with pre- 
cautions and the central point of the seared area grasped so 
that a pyramid or cone of tissue can be cut out, with the 
scissors going quite deep. This is transferred to a sterile petri 
dish and the culture later made from the tip of the cone of 
tissue which has not been heated. It may be touched once to 
the surface of a blood agar plate, and the material thus left 
on the medium spread over the surface with a platinum loop 
or a sterile swab. 

Since with the occurrence of interstitial broncho-pneumonia 
with empyema, extensive collapse of the lung is extremely 
common it becomes difficult to see clearly the areas of con- 
solidation in the atelectatic or airless tissue. There are there- 
fore great advantages in blowing up the lung with air which 
distends the bluish collapsed lung, reddens the blood in its 
capillaries and makes the consolidated area stand out most 
conspicuously. It has the disadvantage that for microscopical 
purposes the condition of atelectasis is done away with, but 
it is easy to excise a small piece for the study of this con- 
dition, or it may be desirable to insufflate only one lung or 
only one lobe. From the point of view of the microscopical 
study, however, the distension of the lung with air makes it 
perfectly easy to understand the condition of the tissue, while 
it is very difficult to disentagle all the changes in a section of 
the collapsed lung. It may also be objected that the contents 
of the bronchi can be forced along into the alveoli. The dis- 
tension may be effected with a bulb with valves, such as is 
furnished with an atomizer, or with the enema syringe or 
with a bicycle pump with a canula tied into the bronchus. 

When the lung is sufficiently distended it should be laid on 
the small table with the main bronchus down and cut through 
from apex to base, with a long knife, with one sweeping stroke 
in the direction shown in the drawing (Fig. 2), so that the 
knife splits the main bronchus longitudinally. Then while 
the lung is still held together in the same position another 
perfectly parallel cut is made about an inch or slightly less 
away from the first one. This will furnish a representative 

6 




Fig. 1 



Page 7 




Bronchus 




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** 



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Fig. 2 



Pa»e !) 



median slice to serve as a museum specimen. If two such 
museum specimens are desired, another or third incision is 
made parallel with the first and just as far on the other side 
of it. If two specimens are not needed, the third incision 
should be made much nearer the first so as to produce a slice 
from top to bottom of the lung about Y% of an inch or 1 cm. 
in thickness. This is for microscopical study and is most 
useful when cut in a complete slice through the lung so that 
large sections may be made for study of the topography of 
the lesions. All these incisions must be made while the lung 
is held together in the original position and are possible only 
when a long and very sharp knife is used and carried through 
with a drawing stroke without undue pressure. The slices 
should be tagged with the number of the autopsy and marked 
also right or left. The most satisfactory tags are made from 
white sheet celluloid cut in small pieces and punched with a 
card punch. The numbers should be written in lead pencil. 
(Such tags will dissolve in strong alcohol or chloroform.) 
They should be sewed to the tissue and the thread tied. Tags 
of hard linen paper marked with lead pencil will answer, but 
soften and tear after long immersion in watery fluids. 

The thicker slice should be washed off and preserved by the 
method of Kaiserling or one of its modifications as described 
in the circular from the Army Medical Museum, or since the 
materials for the solutions intended to preserve the natural 
colors are not always available, it is fairly satisfactory to place 
the specimen in 10 per cent formalin for two days and then 
preserve in 50 per cent alcohol.* 

This specimen should be forwarded with all possible clinical 
and bacteriological data and the protocol of the autopsy to 
the Army Medical Museum, Washington. 



* The method of preservation advised by Klotz has great advantages in 
that specimens may be placed in a single fluid and shipped without further 
treatment after which the colors may be restored on arriving at their 
destination. 

The first fluid which must be used in rather large quantities and freshly 
made up for each batch of specimens is as appears in the following 
directions : 

10 



The thin slice (which, if two median thick slices are pre- 
served, may be cut from the remaining lung just beyond them) 
should be laid flat in Zenker's fluid in an enamel pan. It is im- 
portant that the pan should be large enough to allow the slice 
to lie flat. Since such a slice usually floats, it should be turned 
over once or twice and left in the fluid 21 hours. (Instead 
of the 5 cc. of glacial acetic acid usually added to 95 cc. of 
Zenker's fluid, add 5 cc. of pure formalin just before using.) 
The tissue is then washed in running water for 48 hours and 
preserved in 50 per cent alcohol. Such a slice representing 
as nearly as possible the whole lung should be sent (carefully 
tagged) to the Army Medical Museum in Washington. 

It is obvious that in order that a permanent and representa- 
tive collection may be made which will allow of comparison 
of the respiratory diseases in all the Army camps, it is very 
desirable that medical officers should comply with this request 
and attend especially to the preservation and labelling of 
specimens and the forwarding of the corresponding data. 



1. Fix from three to five days according to the size of the speci- 
men in 

Klotz 1 : 

Carlsbad salts 375 gm. 

Chloral hydrate 375 gm. 

Formalin 375 cc. 

Water 15 liters 

Transferring to fresh solution if necessary during period of fixation. 

Then wash two to three hours in running water and transfer to the 
following for permanent mounting fluid : 

Klotz 11 : 

Carlsbad salts 375 gm. 

Chloral hydrate 150 gm. 

Formalin 75 cc. 

Water 15 liters 

Formula for Carlsbad Salts : 

20 times. 

Potassium sulphate 40 gm. 

Sodium chloride 360 gm. 

Sodium bicarbonate 720 gm. 

Sodium sulphate 880 gm. 

11 



Materials of this sort may be forwarded to the Army Medi- 
cal Museum from any camp through the quartermaster's 
department. 

Boxes of tin or galvanized iron measuring 9 x 9 x 12 inches 
should be made by the tinsmith so that the top may be soldered 
on. It is preferable that the Zenker's fluid specimens should 
be forwarded in a separate can since they tend to stain the 
other specimens unless they have been very well washed. The 
cans should be enclosed in a wooden box for shipment. 

The same method should be employed for the preservation 
of other organs when they present lesions of interest, and in 
any case thin slices of each should be fixed for microscopical 
study. All these pieces of tissue from one autopsy may be 
tied up with a tag in a piece of gauze after the fixation and 
washing is complete. 

Pieces of intestine presenting lesions may be preserved as 
museum specimens by being'pinned out on a board with thumb 
tacks with the mucosa exposed and floated face downward on 
the fixing fluid. The preservation of more complicated in- 
testinal lesions must be left to the ingenuity of each worker. 
In general, slices of solid organs such as the liver or spleen, 
or half of one kidney, make the best museum specimens. In 
all cases the cut surface should be smooth and washed free 
of adhering blood before fixation. As to the preservation 
of the heart one will not go astray in opening the organ if 
the course of the blood is followed with knife or scissors. 

Once more, it should be emphasized that after the organs 
are removed the body must be sewed up carefully and all blood 
stains removed before it is handed over to the undertaker. 
While it is the business of the undertaker to make the body 
presentable, it is the duty of the pathologist to see that no 
body is allowed to leave the autopsy room except in a pre- 
sentable condition, and he will be held personally accountable 
for it. 



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